The ICD-10 Procedure Coding System (ICD-10-PCS) is a US system of

medical classification A medical classification is used to transform descriptions of medical diagnoses or procedures into standardized statistical code in a process known as clinical coding. Diagnosis classifications list diagnosis codes, which are used to track dise ...

used for procedural coding. The

Centers for Medicare and Medicaid Services The Centers for Medicare & Medicaid Services (CMS) is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer ...

, the agency responsible for maintaining the inpatient procedure code set in the U.S., contracted with 3M Health Information Systems in 1995 to design and then develop a procedure classification system to replace Volume 3 of

ICD-9-CM The International Classification of Diseases (ICD) is a globally used medical classification that is used in epidemiology, health management and clinical diagnosis. The ICD is maintained by the World Health Organization (WHO), which is the direc ...

. ICD-9-CM contains a procedure classification;

ICD-10-CM The ICD-10 Clinical Modification (ICD-10-CM) is a set of diagnosis codes used in the United States of America. It was developed by a component of the U.S. Department of Health and Human services, as an adaption of the ICD-10 with authorizatio ...

does not. ICD-10-PCS is the result. ICD-10-PCS was initially released in 1998. It has been updated annually since that time. Despite being named after the WHO's

International Classification of Diseases The International Classification of Diseases (ICD) is a globally used medical classification that is used in epidemiology, health management and clinical diagnosis. The ICD is maintained by the World Health Organization (WHO), which is the dir ...

, it is a US-developed standard which is not used outside the United States.

Section structure

Each code consists of seven alphanumeric characters. The first character is the 'section'. The second through seventh characters mean different things in each section. Each character can be any of 34 possible values the ten digits 0-9 and the 24 letters A-H, J-N and P-Z may be used in each character. The letters O and I are excluded to avoid confusion with the numbers 0 and 1. There are no decimals in ICD-10-PCS Of the 72,081 codes in ICD-10-PCS, 62,022 are in the first section, "Medical and surgical".

Root operations

For medical/surgical, these are the root operation codes: 00 alteration; 01 bypass; 02 change; 03 control; 04 creation; 05 destruction; 06 detachment; 07 dilation; 08 division; 09

drainage Drainage is the natural or artificial removal of a surface's water and sub-surface water from an area with excess water. The internal drainage of most agricultural soils can prevent severe waterlogging (anaerobic conditions that harm root gro ...

; 0B excision; 0C

extirpation Local extinction, also extirpation, is the termination of a species (or other taxon) in a chosen geographic area of study, though it still exists elsewhere. Local extinctions are contrasted with extinction, global extinctions. Local extinctions ...

; 0D extraction; 0F fragmentation; 0G fusion; 0H insertion; 0J inspection; 0K map; 0L occlusion; 0M reattachment; 0N release; 0P removal; 0Q repair; 0R replacement; 0S reposition; 0T resection; 0U supplement; 0V restriction; 0W revision; 0X transfer; 0Y transplantation They can be grouped into several categories: * take out or eliminate all or a portion of a body part: excision ( sigmoid polypectomy), resection ( total nephrectomy), extraction ( toenail extraction), destruction ( rectal polyp fulguration), detachment ( below knee amputation). For biopsies, "extraction" is used when force is required (as with

endometrial biopsy The endometrial biopsy is a medical procedure that involves taking a tissue sample of the lining of the uterus. The tissue subsequently undergoes a histologic evaluation which aids the physician in forming a diagnosis. Medical uses There are a ...

), and "excision" is used when minimal force is involved (as with

liver biopsy Liver biopsy is the biopsy (removal of a small sample of tissue) from the liver. It is a medical test that is done to aid diagnosis of liver disease, to assess the severity of known liver disease, and to monitor the progress of treatment. Medica ...

). See also ectomy. * involve putting in or on, putting back, or moving living body part: transplantation (

heart transplant A heart transplant, or a cardiac transplant, is a surgical transplant procedure performed on patients with end-stage heart failure when other medical or surgical treatments have failed. , the most common procedure is to take a functioning heart ...

), reattachment ( finger reattachment), reposition ( reposition undescended testicle), transfer (

tendon transfer A tendon transfer is a surgical process in which the insertion (anatomy), insertion of a tendon is moved, but the origin (anatomy), origin remains in the same location. Tendon transfer involves redistribution of muscle power, not recreation. Tend ...

) * take out or eliminate solid matter, fluids, or gases from a body part:

(

incision and drainage Incision and drainage (I&D), also known as clinical lancing, are minor surgical procedures to release pus or pressure built up under the skin, such as from an abscess, boil, or infected paranasal sinus. It is performed by treating the area wit ...

), extirpation (

thrombectomy Mechanical thrombectomy, or simply thrombectomy, is the removal of a blood clot (thrombus) from a blood vessel, often and especially endovascularly as an interventional radiology procedure called endovascular thrombectomy (EVT). It thus contr ...

), fragmentation ( lithotripsy of

gallstones A gallstone is a stone formed within the gallbladder from precipitated bile components. The term cholelithiasis may refer to the presence of gallstones or to any disease caused by gallstones, and choledocholithiasis refers to the presence of ...

) * only involve examination of body parts and regions: inspection ( diagnostic arthroscopy), map ( cardiac mapping) * involve putting in or on, putting back, or moving living body part: bypass ( gastrojejunal bypass), dilation ( coronary artery dilation), occlusion ( fallopian tube ligation), restriction (

cervical cerclage Cervical cerclage, also known as a cervical stitch, is a treatment for cervical weakness, when the cervix starts to shorten and open too early during a pregnancy causing either a late miscarriage or preterm birth. In women with a prior spontaneou ...

) * always involve devices: insertion ( pacemaker insertion), replacement (

total hip replacement Hip replacement is a surgical procedure in which the hip joint is replaced by a prosthetic implant, that is, a hip prosthesis. Hip replacement surgery can be performed as a total replacement or a hemi/semi(half) replacement. Such joint replacem ...

), supplement ( herniorrhaphy using mesh), removal ( cardiac pacemaker removal), change ( drainage tube change), revision ( hip prosthesis adjustment) * involve cutting and separation only: division (

osteotomy An osteotomy is a surgical operation whereby a bone is cut to shorten or lengthen it or to change its alignment. It is sometimes performed to correct a hallux valgus, or to straighten a bone that has healed crookedly following a fracture. It i ...

), release ( peritoneal adhesiolysis) * involving other repair: control ( control of postprostatectomy bleeding), repair ( suture of laceration) * with other objectives: alteration (

face lift A facelift, technically known as a rhytidectomy (from the Ancient Greek () 'wrinkle', and () 'excision', the surgical removal of wrinkles), is a type of cosmetic surgery procedure intended to give a more youthful facial appearance. There are m ...

), creation ( artificial vagina creation), fusion (

spinal fusion Spinal fusion, also called spondylodesis or spondylosyndesis, is a surgery performed by Orthopedic surgery#Practice, orthopaedic surgeons or neurosurgeons that joins two or more vertebrae. This procedure can be performed at any level in the spine ...

)

Regions

References

{{Psychotherapy Clinical procedure classification